Pre-hospital care

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Pre-hospital care

Introduction

Pre-hospital care is defined as care and treatment provided at the scene of an accident or acute and sudden illness in an ambulance, emergency vehicle or helicopter (Advanced Life Support Group 2011a, Ahl & Nystrom 2012). Historically, nurses have played an important role in the shaping of pre-hospital emergency care in the UK. The contribution of the hospital flying squad and the cardiac ambulance and the nurses working on them should not be underestimated. Not only did these teams provide a service that filled a therapeutic vacuum in patient care, but they were also instrumental in the development and evolution of these services. The work of both the flying squad and the cardiac ambulance significantly influenced the development of ambulance service and ultimately the birth of the paramedic.

The demise of the hospital flying squad has resulted from a reduced need, partly because of the increasing sophistication of ambulance service provision, enabling ambulance staff to manage increasingly complex clinical situations, complemented by the role played by immediate care doctors responding to incidents in partnership with the ambulance service. Perhaps more influential in the demise of the mobile hospital team has been the increasing workloads of Emergency Departments (ED) and their limited resources to release staff to attend incident scenes on a regular basis.

The role for nurses in responding to the scene of emergency incidents has substantially contracted; however, the potential for nursing input at the scene of a major incident remains a possibility. There are developing areas of pre-hospital practice in which the role of nurses remains, firstly the role in inter-hospital transfer of the critically ill and injured, and secondly working as Emergency Care Practitioners (ECPs).

Whatever role nurses play in their contribution to pre-hospital emergency care, they must be able to do so safely and competently. The professional requirements, set down by the Nursing and Midwifery Council (2008), to provide high standards of practice at all times, to use the best available evidence, to keep skills and knowledge up to date and to recognize and work within the limits of personal competence remain valid when working in the pre-hospital environment just as they do in the ED.

Major incidents

It is neither essential nor desirable for all acute hospitals to be able to provide a mobile team in the event of a major incident. The responsibilities for ensuring mobile teams are available rests with the relevant regional or national health commissioning body. They may nominate those hospitals who will be responsible for deploying a Medical Emergency Response Incident Team (MERIT) to the scene of the incident, if requested to do so (DoH Emergency Preparedness Division 2005). In areas where active immediate care or British Association for Immediate Care (BASICS) schemes are operating, the relevant health board may nominate them to provide the on scene response rather than the acute hospitals. It is, however, essential that the emergency department staff are familiar with the local arrangements in their area.

Those hospitals that are identified as being able to provide a MERIT must ensure staff identified to deploy, the staff must understand the role they are to fulfil in the event of an incident, have the necessary competencies to fulfil that role and have received training to fulfil those competencies (DoH Emergency Preparedness Division 2005, 2007, Bland 2011).

However, there are circumstances, although infrequent, when an ED may be requested to provide medical and nursing support at the scene of a major incident to support their ambulance service colleagues. Given that such incidents are likely to be complex and high profile there is a risk that staff agree to respond without carefully considering if they and their fellow healthcare providers can bring additional expertise that will be of clear benefit to patient care and, in addition, to those services already provided.

Use and function of mobile teams

It is essential that guidelines for the call-out of the team and its intended role are clearly defined in the major incident procedures of all interested parties, predominantly, but not exclusively, the acute hospital, the ambulance trust, and the health authority. There is, unfortunately, a long history of hospital teams being called to the scene of an incident where their role has not been clearly defined beforehand, resulting in the team, at best, contributing little to patient outcome and, at worst, putting themselves and others at risk.

In addition to the clarity of purpose, any proposed team activity must be supported with education, training, rehearsal and operational experience. Failure to do so will result in an ill-equipped, poorly trained, undisciplined team working in an environment in which there is no place for them. The need for regular update training and rehearsal is evermore important because requests for assistance are relatively rare, team members are unlikely to have much experience in this aspect of practice.

Unfortunately there is little guidance available to help organizations identify the best use of the mobile team, the criteria for deployment, the equipment the team should have access to and the training team members require. Although arguing for a medical specialty of pre-hospital and retrieval medicine, the Faculty of Pre-hospital Care, Royal College of Surgeons of Edinburgh, give an insight into what competencies may be required of team members in executing their role (Faculty Pre-hospital Care, Royal College of Surgeons of Edinburgh, 2008). They suggest that the specialist role include:

In addition to the clinical skills required to provide added value to patient care, it is essential that team members have the skills that allow them to operate safely in the pre-hospital environment. They must be both safe and competent to work in environments that are inherently dangerous and where clinical conditions are suboptimal, such as poor lighting, confined spaces, and inclement weather. Additional specialist skills may also be necessary when working at incidents that involve potential hazardous materials.

The problem of an armed perpetrator on scene preventing access to victims is a relatively common problem in so-called ‘spree killing’ incidents. The perpetrators often commit suicide, but even if this happens confirmation of scene safety often takes time. A comprehensive armed police response is almost always more rapid in urban areas, since this is where most incidents occur. A slower response in more rural locations is almost inevitable. In 2010 twelve people were killed by a gunman in Cumbria, a rural county in the UK. The gunman was mobile and was able to operate at multiple locations for more than two hours before shooting himself. In July 2011, where a lone gunman killed 77 people in Norway, the scene at Utøya Island was additionally complicated by the presence of a powerful long-range weapon and separation of the scene from the mainland by water (Lockey 2012).

Training and rehearsal with colleagues from other disciplines is essential in order to understand on scene command and control procedures and the roles adopted by others. The team should provide something in addition to that of other members of the multidisciplinary team. There is little point in a team arriving on scene and replicating the care that could easily be provided by the ambulance service, and who are more familiar with the operating environment from their day-to-day work.

Potential team members must be familiar with their local plan, to be aware of any requirements for them to provide a MERIT, and their role in the team if requested to participate. Plans should provide outline guidance on the role of the MERIT; however, it is incumbent upon the Ambulance Incident Commander (AIC) and the Medical Incident Commander (MIC) to clearly define the role and purpose of deploying a MERIT and giving advice on the best way of executing their role (DoH Emergency Preparedness Division 2005). This guidance provides examples of the specific skills the team may bring to the scene, such as provision of analgesia or the specialist support of children. There is, however, a clear expectation that the team has received appropriate training for this role.

Resourcing the team often results in the hospital being depleted of key, experienced personnel at a time when their expertise is in greatest demand. Plans must take this into account, ensuring that those required by the regional health board to provide a MERIT response are able to take action to ensure that a team can be assembled with appropriately skilled staff, when required to do so. The plan should not require action that would knowingly deplete essential services and expose the organization and patients to unacceptable risk.

The plan should also identify the equipment that is available to the MERIT, ensuring that it is appropriately packaged for clinical needs, operation and manual handling. The team must also have access to appropriate personal protective equipment, primarily for their safety but with due consideration to the identification of team members and key roles. Staff must therefore be familiar with the clinical and safety equipment they require and the safe and appropriate use of that equipment in the pre-hospital environment. Equipment should, as far as possible, be both compatible and interchangeable with the local ambulance service (Box 1.1).

Box 1.1   Essential equipment for mobile teams

• Carbon fibre helmet with chin strap and visor. Helmet should be green in colour with ‘nurse’ or ‘doctor’ in white lettering on each side

• Ear defenders — for team members and the patient

• Fire-retardant suit — designed to offer some protection to the wearer should a fire occur, but not designed to allow the wearer to enter a fire

• Warm underclothing — essential during cold weather, especially if the incident is likely to be protracted

• High-visibility jacket — with designation clearly marked front and back. Jacket to have green shoulder and fluorescent lower section with reflective bands

• Heavy duty gloves

• Latex gloves

• Oil- and acid-resistant boots. Wellington boots are not appropriate for the demands of pre-hospital care; they are cold, limit movement and are prone to having liquids poured into them

(After Hodgetts T, McNeill I, Cooke M (2000) The Pre-Hospital Emergency Management Master. London: BMJ Publishing Group.)

Deployment of the team

Deployment of the team is often delayed, principally for logistical reasons, such as assembly of the team, collection of the equipment, and availability of transport for the team. Transport is a particular problem as most ambulances and their staff will be committed to patient care and transport and it may be some time before a vehicle is made available to transport the team. In the case of natural disasters, such as flooding or earthquakes, transport may be particularly badly affected due to road damage and loss of infrastructure (Dolan2011a, b, Dolan et al. 2011).

The AIC is responsible for coordinating ambulance resources at the scene of the incident and, in conjunction with the MIC, coordinating the activity of other NHS resources at the scene of the incident. On arrival at the scene the MERIT must report to the MIC, or the AIC if the MIC has not yet arrived on scene. Under no circumstances should the MERIT self-task at the scene.

The MERIT is likely to deploy close to the incident site, but outside the inner cordon surrounding the actual incident site, a casualty clearing point will be established. This is the interface between the incident site and the chain of evacuation. It is at this point that the MERIT may be of most use.

Triage for transport

Patients will initially be treated by ambulance personnel prior to evacuation to the casualty clearing point. At the casualty clearing station the mobile team will reassess patients prior to making further treatment and transport decisions, identifying those patients who should be dispatched to hospital immediately and those who may wait a short time. The team may also become involved in the care of the critically injured and those patients with less severe injuries prior to their transportation to the receiving hospital. The team should be able to provide complex clinical interventions such as anaesthesia, sedation, and complex pain management. The team may be also able to provide interventions that currently fall outside the remit of ambulance paramedics, such as tube thoracotomy.

Clinical prioritization and decision making may be assisted by the use of major incident triage algorithms. These algorithms vary from the conventional triage operated on a daily basis in the emergency department as they give a low priority for both treatment and transportation of those with critical injury, who will require large amounts of resource to care for them and are unlikely to survive. Where resources are plentiful these patients would be of a high priority, but in a major incident their priority is low, given that providing the required resources may deprive many others, with potentially survivable injuries, of care. This form of triage is often difficult for nurses and doctors to accept, but the aim is to do the greatest good for the greatest number (Barnes 2006).

Triage for treatment usually follows the triage sieve approach (Life Support Group 2011a). This is a physiologically based system that considers the ability to walk, the patency of the airway, the respiratory rate and the capillary refill rate of pulse rate. The physiological parameters are appropriate for adults (Fig. 1.1). For children, the paediatric triage tape provides a suitable alternative with age-appropriate physiological parameters, whilst retaining the algorithm structure of the triage sieve (Wallis & Carley 2006).

image

Figure 1.1 Triage sieve. (After Hodgetts T, Cooke M, McNeill I (2002). The Pre-Hospital Emergency Management Master. London: BMJ Books.)

After initial treatment in situ and in the casualty clearing station, patients must be prioritized for transport to hospital. Triage for transport employs the triage sort system (Life Support Group 2011a), which is somewhat less crude than the triage sieve. The triage sort requires the measurement of the Glasgow Coma Scale, respiratory rate and systolic blood pressure (Fig. 1.1). Again this relates specifically to adult patients. For children the Paediatric Early Warning Score (PEWS) (Duncan et al. 2006) or Paediatric Advanced Warning Score (PAWS) (Advanced Life Support Group 2011b, Egdell et al. 2008) systems may be more appropriate.

Inter-hospital transfer

There is an increased awareness within the ambulance service that patients need not be taken to the closest emergency department, but to a hospital most likely to be able to meet their needs. For example, it may be permissible to take a patient with a serious head injury directly to a hospital with neurosurgical facilities and bypass the local emergency department. This principle is well established in patients with confirmed acute myocardial infarctions being taken directly to hospitals providing emergency primary angioplasty services. The practice of bypassing local emergency departments has become increasingly viable with the proliferation of air ambulance services.

There are, however, still occasions where the critically ill or injured patient must be transferred from one hospital to another. This work may be undertaken by air ambulance services, some operating 24 hours per day, but others restricted to flying during daylight hours. A number of patients continue to be transported between facilities with the need for a nurse or nurse and doctor escort. There remains the debate whether this role should be undertaken by emergency nurses or by critical care nurses.

The fact remains that from whatever discipline the nurse comes from they must have the requisite skills to be able to care for the patient in transit. The professional requirements remain in that the nurse must recognize and work within the limits of personal competence (NMC 2008). One might argue that the requisite skills mirror those identified by the Faculty of Pre-hospital Care, Royal College of Surgeons of Edinburgh (2008):

One would also expect that nurses intending to adopt this role had developed the skills and competencies through training and rehearsal. In particular they should be familiar with the specific issues that result from the environment. They must be able to work in a confined space and in a moving vehicle. They must also be aware of the difficulties that occur, including not having limitless supplies of electricity or oxygen. For example, will infusion pumps have sufficient battery power to last the journey, even if the journey is delayed or the infusion rate is increased? Is there sufficient oxygen to ventilate the patient for the entire journey, again including unexpected delays or an increase in the required inspired oxygen?

Equipment used for inter-hospital transfers must be fit for purpose and, where possible, interchangeable with the ambulance service. Equipment must also be adequately package for the environment, given the limited space, lack of surfaces for equipment, and appropriate means for securing in the vehicle. It is not appropriate to take unsecured and loose pieces of equipment on a transfer. It is equally unacceptable for a handful of drugs to be taken in a vomit bowl or in the nurse’s pocket. Transfers must be conducted in a safe and professional manner.

Emergency care practitioner

In 2000 the Joint Royal Colleges Ambulance Liaison Committee proposed the development of the role of the Practitioner in Emergency Care (PEC). This work introduced the concept that some patients could be adequately assessed and treated at home or the scene of incident without the need for transportation to hospital. Up until this point the vast majority of patients attended by the ambulance service would be transported to the local emergency department.

Over the past decade the role has evolved into that of the Emergency Care Practitioner (ECP); however, the title PEC was never really adopted. Despite a promising start the role of the ECP has not developed as quickly as many would have liked and the numbers of trained ECPs working in ambulance trusts is variable. However, despite some reservations and operational difficulties one interesting development appears to have endured, the employment of emergency nurses as ECPs alongside their paramedic-qualified ECP colleagues. Perhaps this should not be entirely surprising as the skills required in the assessment, treatment and discharge of patients with mainly minor injuries and illness is well established in the role of the Emergency Nurse Practitioner. There are, of course, new skills for emergency nurses working as ECPs to develop, some more obvious than others. For example, emergency nurses used to working in teams need to adapt to be comfortable working as a solo responder, without the range of equipment and patient testing available in the emergency department. Wound care including suturing, for example, has some added complexity in the patient’s home when compared with a treatment room in the emergency department.

ECPs may be tasked to a range of emergency calls, such as cardiac arrests or road traffic collisions. This often presents nurse ECPs with a steep learning curve; learning advanced driving skills, scene assessment and management, and resuscitation as a solo responder. Many skills are transferable, but the emergency nurse should not assume that because they are, for example, an Advanced Life Support (ALS) provider they would be able to manage a cardiac arrest single handed in the community. Emergency nurses have much to learn from their paramedic colleagues as paramedics have much to learn from their emergency nurse colleagues.

References

Advanced Life Support Group. Major Incident Medical Management and Support: The Practical Approach at the Scene, third ed. London: BMJ Books; 2011.

Advanced Life Support Group. Advanced Paediatric Life Support: The Practical Approach, fifth ed. London: BMJ Books; 2011.

Ahl, C., Nystrom, M. To handle the unexpected: The meaning of caring in pre-hospital emergency care. International Emergency Nursing. 2012;20(1):33–41.

Barnes, J. Mobile medical teams: Do A&E nurses have the appropriate experience? Emergency Nurse. 2006;13(9):18–23.

Bland, S. Pre-hospital emergency care. In: Smith J., Greaves I., Porter K., eds. Oxford Desk Reference: Major Trauma. Oxford: Oxford Medical Publications, 2011.

Dolan, B. Rising from the ruins. Nursing Standard. 2011;25(28):22–23.

Dolan, B. Emergency nursing in an earthquake zone. Emergency Nurse. 2011;19(1):12–15.

Dolan, B., Esson, A., Grainger, P., et al. Earthquake disaster response in Christchurch, New Zealand. Journal of Emergency Nursing. 2011;37(5):506–509.

Duncan, H., Hutchison, J., Parshuram, C.S. The Pediatric Early Warning System score: A severity of illness score to predict urgent medical need in hospitalized children. Journal of Critical Care 09. 2006;21(3):271–278.

Egdell, P., Finlay, L., Pedley, D.K. The PAWS score: Validation of an early warning scoring system for the initial assessment of children in the emergency department. Emergency Medicine Journal. 2008;25(11):745–749.

Hodgetts, T., Cooke, M., McNeil, T., The Pre-Hospital Emergency Management Master, London, BMJ Books, 2002.

Wallis, L.A., Carley, S. Validation of the paediatric triage tape. Emergency Medicine Journal. 2006;23:47–50.

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